Provider Demographics
NPI:1093859795
Name:OLD PUEBLO DRUG
Entity Type:Organization
Organization Name:OLD PUEBLO DRUG
Other - Org Name:OLD PUEBLO DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MYRON
Authorized Official - Middle Name:
Authorized Official - Last Name:GINSBURG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-455-0058
Mailing Address - Street 1:PO BOX 508
Mailing Address - Street 2:
Mailing Address - City:SONOITA
Mailing Address - State:AZ
Mailing Address - Zip Code:85637-0508
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3272 HWY 82
Practice Address - Street 2:
Practice Address - City:SONOITA
Practice Address - State:AZ
Practice Address - Zip Code:85637
Practice Address - Country:US
Practice Address - Phone:520-455-0058
Practice Address - Fax:502-455-4782
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AZYO29833336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ307787Medicaid
1997300OtherPK
AZ307787Medicaid